神经电刺激治疗慢性头面部疼痛：综述（十）

 英语晨读 ·

山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。

本次文献选自Antony AB,  Mazzola AJ,  Dhaliwal GS, et al. Neurostimulation for the Treatment of Chronic Head and Facial Pain: A Literature Review[J]. Pain Physician, 2019, 22(5):447-477. 本次学习由陈阳住院医师主讲。

Physical Therapy

Similar to most chronic pain syndromes, physical therapy (PT) can offer therapeutic benefit. PT has been mostly studied in migraine patients and has been shown to increase the patient’s perception of change and overall satisfaction to migraine treatment. PT has been demonstrated to reduce nociceptive afferents in the craniocervical region. Although there remains limited evidence suggesting PT or aerobic exercise improves frequency or duration of headaches, PT remains a useful tool with minimal risk and possible improvement in overall pain intensity.

物理疗法

与大多数慢性疼痛综合症相似，物理疗法（PT）可以提供治疗益处。PT主要在偏头痛患者中进行研究，结果表明可以提高患者对偏头痛治疗的变化感知和总体满意度。PT已被证明可以减少颅颈区域的伤害感受传入。尽管鲜有证据表明PT或有氧运动可改善头痛的频率或持续时间，但PT仍是一种有用的工具，其风险最小且可能改善总体疼痛强度。

Psychological Treatment

A holistic approach often includes behavioral therapy. Biofeedback has shown positive outcomes in treating tension and migraine headaches. Biofeedback allows the patient to be informed on the physiologic process that is occurring, bringing the patient new awareness on their condition. In theory, the patient will be able to use this knowledge to learn how to voluntary control the previously involuntary processes of pain. Feedback is often provided through electromyography in various muscles or through topical temperature readings.

Cognitive-behavioral therapy takes advantage of the link between emotional factors and pain. Therapy usually includes relaxation training, operant conditioning, and focusing on specific attitudes and beliefs that may trigger behavioral or emotional pain responses. Social support groups have proven to be beneficial in patients with chronic pain, including migraine.

心理治疗

整体方法通常包括行为疗法。生物反馈在治疗紧张性疼痛和偏头痛方面已显示出积极的成果。生物反馈使患者可以了解正在发生的生理过程，从而使患者对其状况有了新的认识。从理论上讲，患者将能够使用该知识来学习如何自我控制以前非自愿的疼痛过程。反馈通常通过肌电图或局部温度来提供。

认知行为疗法利用了情感因素与疼痛之间的联系。治疗通常包括放松训练、条件反射调节、以及关注可能触发行为或情绪上疼痛反应的特定态度和信念。事实证明，社会支持团体对包括偏头痛在内的慢性疼痛患者有益。

Acupuncture

Acupuncture has been trialed in areas of the head and face. For TN, acupuncture has shown to reduce severity of attacks. In addition, several studies have concluded that acupuncture treatment may be beneficial when compared with current prophylactic drug therapy in preventing and treating both migraine and tension headache.

针刺

针刺已经在头面部疼痛进行尝试。对于TN，针灸可降低发作的严重程度。此外，一些研究得出的结论是，与目前的预防性药物治疗相比，针灸治疗在预防和治疗偏头痛和紧张性头痛方面可能是有益的。

Trigger Point Injection

Although common in clinical practice, there is little data on the efficacy of trigger point injections for treatment of craniofacial pain. There is no defined optimal drug regimen or injection schedule. In patients with tight or tender muscles, routine trigger point injections may provide some symptomatic relief.

扳机点注射

尽管在临床实践中很普遍，但是关于扳机点注射治疗颅面痛的疗效的数据很少。没有明确最佳的药物或注射治疗方案。对于肌肉紧绷或触痛的患者，传统的扳机点注射可能会缓解一些症状。

Botulinum Toxin Injection

Injections with onabotulinumtoxinA in the pericranial muscles has been approved for CM headaches since 2010 by the US Food and Drug Administration. Diener et al described the technique of 31 separate fixed-site intramuscular injections each delivering 5 units of onabotulinumtoxinA for a total dose of 155 units. The injections were divided over 7 defined head and neck muscle areas: corrugator, procerus, frontalis, temporalis, occipitalis, cervical paraspinal and trapezius. Depending on the patient’s symptoms, an additional 40 units may have been given to the occipitalis, temporalis, and/or trapezius muscle groups. After 2 cycles separated by 12 weeks, there were positive outcomes including reduction in disability and improvement in function, vitality, and quality of life. The authors conclude onabotulinumtoxinA is effective for prophylaxis of headache in adults with CM. A recent review of guidelines reports onabotulinumtoxinA is safe and effective for reducing the number of headache days in patients with CM, but is ineffective for patients with episodic migraine and is probably ineffective for treating chronic tension-type headaches. In addition, botulinum toxin has been trialed for facial nerve pain and spasms, such as in TN, however, larger studies are required.

肉毒杆菌毒素注射

自2010年以来，美国食品和药物管理局已批准在颅面部肌肉中注射肉毒杆菌毒素A治疗CM。Diener等人报道了一种技术，即分别在31个固定部位肌肉注射5u的肉毒杆菌毒素A，总剂量为155u。注射分为7个确定的头颈部肌肉区域：眉肌、降眉间肌、额肌、颞肌、枕肌、颈部椎旁肌和斜方肌。根据患者的症状，枕肌、颞肌和/或斜方肌群可能会另外分配40u。在两个疗程（间隔12周）后，出现了积极的结果，包括无力的减少以及功能、活力和生活质量的改善。作者得出结论，肉毒杆菌毒素A对预防成人CM有效。最近的指南回顾表明，肉毒杆菌毒素A对于减少CM患者的头痛天数是安全有效的，但对发作性偏头痛患者无效，并且可能对治疗慢性紧张性头痛无效。此外，肉毒杆菌毒素已经被试用于面神经痛和面肌痉挛（例如TN），但是，还需要进行更多的研究。